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Intervention Ch. 48


Skin is the bodies largest? Organ
The skin a protective barrier against? disease causing organisms, a sensory organ for pain, temperature, and touch, and it synthesizes Vitamin D
What are the 2 layers of the skin? epidermis and the dermis
What is the membrane that seperates them? the dermal-epidermal junction
The epidermis has? several layers
What is the outermost layerr of the epidermis? stratum corneum
What is the innermost epidermal layer? basal layer
Cells in the basal layer? divide, proliferate, and migrate toward the epidermal surface
What does the stratum corneum protect underlying cells and tissues from? dehydration, and prevents entrance of certain chemical agents
What does the dermis provide? strength, mechanical support and protection to the underlying muscles, bones and organs.
How doe sthe dermis differ from the epidermis? is contains mostly connective tissue and few skin cells
What is collagen? a tough, fibrous protein
What are responsible for collagen formation? fibroblasts
What does age do to skin? it makes skin more vulnerable to damage
What is a pressure ulcer? localized injury to the skin and other underlying tissue, usually over a body prominence, pressure and friction
Who is at risk for pressure ulcers? decreased mobility, decreased sensory perception, incontinence, and poor nutrition
prolonged intense pressure affects? cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ishemia and then tissue death
What are the 3 pressure related factors contributing to pressure ulcer development? 1. pressure intensity, 2. pressure duration, 3. tissue tolerance
If a capillary exceeds the normal capillary pressure, and the vessel is occluded for a prolonged period of time what can occur? tissue ischemia
How is tissue ischemia discovered? pressure is relieved and the blood flow returns means there isn't any, but if you apply pressure and the blood is not returned tissue ischemia is present
What is reactive hyperemia? Where blood returns after pressure on skin
What is blanching erythema? Where blood is not present when there is pressure on skin
Blanching does not occur in what pt's? Dark pigmented skin
What is darkly pigmented skin? skin that remains unchanged when pressure is applied over a bony prominence, iffecpective of the client's race or ethnicity
Low pressure or high pressure for a short time causes? tissue damage
prolonged pressue causes? tissue death
As a nurse you should assess what about pressure and the pt? evaluating the amount of pressure and determining the amount of time that a client tolerates pressure
What does the ability of tissue to endure pressure depend on? integrity of tissue and the supporting structures
If the factors of shear, friction, and moisture are present the more susceptible the skin will be to? damage from pressure
Clients with altered sensory perception for pain and pressure are more? At risk for impaired skin integrity
Impaired mobility increases? risk of pressure ulcer
pt's who are confused are unable to protect themselves from? pressure ulcer
What is shear? the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance between the client and the surface
What is friction? 2 surfaces moving across one another, such as the mechanical force exerted when skin is dragged across a coarse surface
Friction affects what? the epidermis or top layer of the skin
What friction has occured the skin will appear? red and painful "sheet burn"
Friction injury occurs is pt's who? are restless, in those who have uncontrollable movement, and those who have their skin dragged
The presence and duration of _____ on the skin increases the risk of ulcer formation? moisture
Prolonged moisture _______ skin and makes it more suseptible moistens
Where does skin moisture originate from? wound drainage, excessive perspiration, and fecal or uninary incontinence
What does an assessment of a pressure ulcer include? type, depth of involvement, approx. % of tissue in wound bed, wound dimensions, exudate description, and condition of surrouding skin
What are staging systems for pressure ulcers? how deep tissue is destroyed
What must be removed to expose the wound so you can stage it? nectrotic tissue
Stage 1: intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage 2: Partial-thickness skin loss involving epidermis, dermis, or both. the ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater
Stage 3: Full thickness tissue loss. subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. slough may be present but does not obscure the depth of tissue loss. may include undermining and tunneling
Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar may be present on some parts of the wound.. often includes underming and tunneling
What is an unstageable ulcer? is full thickness tissue loss in which the base of the ulcer is covered by slough or char in the wound bed
For a wound with nonaviable tissue you will need to assess? the type of tissue in the wound base
What does the assessment of tissue type include? amount and apperance of viable and nonviable tissue
What is granulation tissue? red moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.
What is soft yellow or white tissue charecteritic of? slough (stingy substance)
What is black and brown nectrotic tissue? eschar
What do you use to measure a wound? desposable wound measuring devices
How do you measure depth of a wound? used a cotton tipped applicator
What is wound exudate? is describes the amount, color, consistency, and odor of drainage and is part of the wound assessment
What does excessive exudate indicate? the presence of infection
What do you assess the tissue around the wound? redness, warmth, maceration or edema
What is a wound? integrity and function of tissues in the body
All wounds are not created? equal
Wound classification systems describe? The status of skin, integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, or descriptive qualities of the wound tissue such as color
What do wound classifictions allow nurses to do? enable the nurse to understand the risks accosiated with a wound and implications
What are the two types of wounds: those with loss of tissue and those without
What heals with primary intention? surgical wounds
Sugical wounds edges are? approximated, or closed
What heals with secondary intention? a wound involving loos of tissue, such as a burn, pressure ulcer, or severe lacteration
The wound is left open until when? scar tissue fills it
It takes longer for a wound to heal using? secondary intention
what are partial thickness wounds? shallow wounds involving loss of the epidermis and possibly partial loss of the dermis
How does partial thickness wounds heal? by regeneration
Pressure ulcers are an example of what? full thickness wounds
What are the 3 components involved in the healing process of partial thickness wounds? 1. inflammation, epithelial proliferation and migration, and reestablishment of the epidermal layers
A wound left open to air can resurface within? 6 to 6 days
A wound that is kept moist can resurface in? 4 days
Epidermal cells only? Migrate accross a moist surface
In a dry wound the cells? migrate down to a moist surface until they can migrate
New eptthelium is only a few cells thick and must undergo? restablisment of the epidermal layers
What are the 3 phases involved in the healing process of a full thickness wound? are inflammartory, proliferative, and remodeling
What is the inflammatory phase? the body's reaction to wounding and begins within minutes of injury and last approximately 3 days
What happens during hemostatis? injured blood vessels contrict, and platelets gather to stop bleeding
What do clots form? a fibrin matrix that later provides a framework for cellular repair
Damage tissue and mast cells secrete? histamine
Leukocytes reach the wound? within a few hours
What is the primary active white blood cell? a neutrophil
What do neutrophils do? ingest bacteria and small debris
What is the second important leukocyte? monocyte with transforms into macrophages
What to macrophages secrete? growth factors that attract fibroblasts
What is the main component of scar tissue? collagen
Too much imflammation also prolongs healing because? arriving cells compete for nutrients
When does the proliferative phase begin? with the appearance of new blood vessels
How long does it last? 3-24 days
What are the main activities during the proliferation phase? filling the wound with granulation tissue, contraction of the wound, and the resurfacting of the wound by epithelialization.
What synthesizes collagen? fibroblasts
Collagen mixes with granulation tissue and this matrix will support? reepithelialization
What does collagen provide? strength and structural integrity to a wound
In a clean wound the proliferative phase accomplishes what? the vascular bed is reestablished, the area is filled with replacement tissue, and the surgace is repaired
Maturation is the final stage of healing and can take? 1 year
Usually scar tissue contains fewer? pigmented cells and has a lighter color than normal skin
What is hemorrhage? bleeding from a wound site
Hemostasis occurs within several minutes unless? large blood vessels are involved or the client has poor clotting function
Hemorrhage occurs? externally or internally
What is a hematoma? localized collection of blood underneath the tissues
How does a hematoma appear? a swelling, change in color, sensation or warmth or mass
Why is a hematoma bad by a major artery or vein? it can obstruct blood flow
What is the second most common infection? wound infection
How do you know a wound is infected? purulent material drains from it
All chronic dermal wounds are considered? contaminated with bacteria
It is generally agreed that wounds with more than how many organims are infected? 100,000
Wound infection increases when there is? necrotic tissue, foreign bodies in the wound, and the blood supply and local tissue defenses are reduced
Some wounds show infection in how many days? 2 or 3 days
when does a surgical wound show infection? 4-5 days
How do you know there is an infection? pt has fever, tenderness, and pain at the wound site, and an elevated WBC count
When a wound does not heal properly there is? skin and tissue seperation
What is dehiscence? the partial or total separation of wound layers
A person at risk for poor wound healing is at risk for? dehisence
Who have a greater risk for dehiscence? obese people
You should know that when there is an increase in ___________ drainage from a wound there is a greater risk for dehiscence? serosanguineous
What is a good strategy to prevent dehisence? using a blanket or pillow over the abdomen site
What is eviseration? total separation of wound layers, where there is protrusion of visceral organs through a wound opening
What does the nurse do when eviceration occurs? the nurse places sterile towels soaked in sterile saline over the sxtruding tissues
What is a fistula? an abnormal passage between two organs or between an organ and the outside of the body
What are the common reasons fistula's form? as a result of poor wound healing or as complication of disease
Fistulas increase the? risk of infection and F&E imbalances
Prevention and treatments of ulcers is a? major nursing priority
The norton scale and the braden scale are used for? pressure ulcer risk assessments
What are norton's five risk factors? physical condition, mental condition, activity, mobility and incontinence; score ranges from 5-20, lower score=high risk
What was the braden scale used for? Nursing homes
What are braden's 6 subscales? sensory perception, moisture, activity, mobility, nutrition, and friction and shear; score ranges from 6 to 23, lower score= higher risk
What is the most commonly used assessment scale for pressure ulcer risk? Braden scale
Pressure ulcers usually develop when? within the first 2 weeks of hospitilization
When a pressure ulcer occurs it effects the pt how at the hospital? the length of stay and the cost increase
Normal wound healing requires? proper nutrition
wound healing relies on? protein and vitamins, zinc and copper
What is vitamin C for? synthesis of collagen
What is vitamin A for? reduce the negative effects of steroids on wound healing
What is zinc for? epithelialization
What is copper for? collagen fiber linking
The study of prealbumin provides? what the pt has eaten, absorbed, digested, and metabolized
What fuels that cellular functions essential to the healing process? oxygen
What shows that an infection is present? pus, odor, volume change, character of wound drainage, redness, fever, and pain
Body image changes influence? self concept and sexuality
What factors affect the pt's perception of a wound? scars, drains, odor from drainage, and temporary or permanent prosthetic device
Critical thinking is? always changing
What guides skin assessment? focusing on specific elements such as the pt's level of sensation, movement, and continence status
Pay special attention to skin over? body prominences, or in a cast
Also assess the pt's response to? pressure
When you suspect abnormal reactive hyperemia? outline the affected area with marker
when assessing for pressure ulcers you should? use appropriate predictive measure and alles the client's mobility, nutrition, presence of body fluids, and comfort level
Once you think a person is at risk for pressure ulcer's you should? implement prevetion stratgies
For assessing motility you should? document muscle tone, stength, and activity tolerance
Malnutrition is a major risk factor for? pressure ulcer development
What body fluids give the greatest risk for skin breakdown? gastric and pancreatic
What two conditions do you often assess wounds? At the time of injury before treatment, and after therapy
What is an abrasion? superficial with little bleeding and is considered a partial thickness wound
What is a laceration? more bleeding because of depth and location
What is puncture wounds? Bleed because depth and size of wound
What is the primary danger of puncture wounds? infections
Do not take a dressing off until? it is ordered
When taking off a dressing you should asses whether the? wounds edges are closed
For wound drainage you should note? the amount, color, odor, and consistency of drainage
What are types of drainage? serous, sanguineous, and serosanguneous, and prulent
Why would you incert a drain? if there is a large amount of drainage
What should you assess about drains? drain placement, character of drainage, condition of collecting equipment
A sudden decrease in tubing could be? a blockage
What jackson pratt? exerts a constant low pressure as long as the suction device is fully compressed
If fluid accumulates? The wound will not heal
How are surgical wounds closed? staples, sutures, and wound closures
What are two initial defenses for preventing skin breakdown? assessment and skin hygeine
When cleaning skin do not use? soap or hot water
Clients need respositioned? every 2 hrs
What are support surfaces? therpeutic beds and mattresses
What is the goal of effective wound management? maintenance of a physiological local wound enviroment
to maintain a healthy wound enviroment you should? manage infections, cleanse the wound, remove nonvialbe tissue, manage exudate, maintain the wound in a moist enviroment, and protect the wound
How do you clean a pressure ulcer? saline or noncytotoxic cleaners
What is the most common method of getting solution to a wound? irrigation
What is the epidermis? top layer of skin
What is the dermis? inner layer (strength, support, blood vessels, collagen, connective tissue)
Blanching that stay white may indicate? deep tissue damage
What are the 3 healing processes? primary, secondary, tertiary
How will a partial thickness wound repair? inflammatory, epithelial proliferation, and migration (LIKE NEW)
How will full thickness wound repair? inflammatory, proliferation and remodeling (SCAR)
What are possible things that could go wrong with wounds? hemorrhage, infection, dehiscence, eviseration, fistla
What is the best nursing action for wounds? PREDICT AND PREVENT
What do you assess about a wound? appearance, drainage, drains, wound closures, palpate wound, culture
For a culture you should do what first? clean the wound
How do you prevent wound formatio? clean skin daily, position, support surfaces
If infected a wound? will not heal
What may be necessary for a wound? debridement or irrigation
Excessive exudates are? bad
How do you clean a wound? center out, be gentle, Ns preferred
Pressure ulcers NEED? dressings
Created by: alicia.rennaker
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